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General Practice UK > Contraception GP > Flashcards

Contraception GP Flashcards

Essentials for contraceptive prescribing

1
Q

List the main contraceptive methods.

A

IUD = copper coil

IUS = progesterone coil

SDI = progesterone implant

POI = progesterone-only injectable

POP = progesterone-only pill

CHC = combined hormonal contraceptive

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2
Q

Which guidance advises on contraindications for contraceptive methods?

A

UK Medical Eligibility Criteria (UKMEC), based on evidence and consensus opinion

Adapted from international WHOMEC by FSRH (Faculty for Sexual and Reproductive Healthcare)

http://www.fsrh.org/ukmec/

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3
Q

How many UKMEC categories are there, what do they mean?

A

UKMEC categories 1 to 4

  1. Always usable
  2. Broadly usable
  3. Counsel/caution
  4. Do not use
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4
Q

Examples for UKMEC 4 (contraindicated)?

A

All hormonal methods (CHC, POP, DMPA, IUS) contraindicated in current breast cancer

Combined hormonal contraceptives (CHC) in

  • migraine with aura / focal migraine
  • BP >160/95
  • <6w post-partum (due to thrombosis risk <3w and reduced milk volume <6w)
  • SLE with unknown or documented antiphospholipid antibodies
  • major surgery with prolonged immobilisation
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5
Q

Definition of Pearl index?

A

Pearl index = number of pregnancies occuring per 100 women years (a women year defined as 13 menstrual cycles)

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6
Q

Limitations of Pearl index?

A

Limitations of Pearl index

  • reflects perfect use - user-dependent methods (e.g. pills) have a higher Pearl index (pregnancy risk) in typical use / real life
  • does not reflect natural change in pregnancy risk over time (index is given as 85 independent of age)
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7
Q

Examples of Pearl index for common contraceptive methods.

A

No method: 85 (of 100 women pregnant/year)

Condom: 2 (18 in typical use)

POP or CHC: 0.3 (9 in typical use)

DMPA: 0.2 (6 in typical use)

IUD (0.8) or IUS (0.2) in typical use

Subdermal implant most effective: 0.05 in typical use

Sterilisation: female 0.5 / male 0.15

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8
Q

What are Combined Hormonal Pills (CHC) made of?

A

An oestrogen and progesterone,

Oestrogen is ethinyloestradiol, mostly 30 micrograms (20, 30, 35, 50 available)

Progesterone generations:

  1. Norethisterone
  2. Levonorgestrel
  3. Desogestrel, Gestodene
  4. Drospirenone
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9
Q

First line choice of CHC (recommended by FSRH)?

A

A 30mcg pill containing either

  • Norethisterone (Loestrin 30) or
  • Levonorgestrel (Rigevidon, Ovranette, Microgynon, Levest, …)
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10
Q

Second line options of CHC, if woman experiences side-effects?

A

Oestrogenic side-ffects: nausea, headache, dizziness, breast tenderness, cyclical weight gain

  • Try lower dose oestrogen e.g Loestrin 20, or
  • more progesterone dominant e.g. Levonorgestrel-based pills

Progestogenic side-effects: weight gain, mood swings, acne, seborrhoea, hirsutism

  • Try an oestrogen-dominant pill, or
  • 3rd or 4th generation e.g. Gedarel, Marvelon, Femodene, Lucette

Breakthrough bleeding: Check compliance, check cervical screen up to date, do pelvic exam +/- STI screen

  • Then, try higher dose oestrogen, or
  • 3rd or 4th generation pill
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11
Q

How can a woman take the CHC pill, i.e. what regimes are there?

A
  • Traditional 21/7 regime
  • Shorter hormone-free interval e.g. 24/4
  • Extended: 2 or 3 strips consecutively, followed by a 4 (up to 7) day break
  • Unscheduled cycles: take continuously, with a 4 (up to 7) day break when breakthrough bleeding occurs
  • Continuous: take pill every day whether breakthrough bleeding occurs or not
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12
Q

Advantages of extended CHC regimes and shortened hormone-free interval?

A

Extended regimes

  • fewer menstrual symptoms like headaches, pain, bloating
  • suppresses endometriosis and PMS
  • reduced failure rate

Shortened hormone-free interval (4 days)

  • less chance of ovulation
  • resulting in lower failure rate

Endorsed by FSRH but unlicensed

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13
Q

Missed pill rules?

(for CHC except Qlaira and Zoely)

A

It is a missed pill once taken >24h late.

One missed pill: take missed pill together with today’s pill, continue with the rest of the pack, no further action

Two or more missed pills: take one missed pill together with today’s pill (discard remaining missed pills), continue with the rest of the pack, use extra precautions for 7 days, if unprotected sex in previous 7 days may need emergency contraception

http://www.fsrh.org

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14
Q

How does taking CHC influence the risk of cancer?

A

A small increase in risk of breast and cervical cancer, which reduces after stopping and is back to normal after 10 years.

UKMEC is 1 for family history of breast cancer, 3 for BRCA mutation carriers, and 4 for current breast cancer.

Reduced risk of ovarian, endometrial and colorectal cancer.

No increase in risk of mortality or overall cancer risk.

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15
Q

How do CHC affect venous thrombosis (VTE) risk?

A

Annual risk of VTE (per 10,000 women)

  • Not pregnant and not using CHC: 2
  • 1st or 2nd gen CHC: 5-7
  • 3rd or 4th gen CHC: 9-12
  • pregnant: 29
  • postpartum: 300-400
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16
Q

UKMEC regarding CHC and venous thrombosis?

A

UKMEC 4 (absolute contraindications)

  • personal history of VTE
  • known thrombogenic mutation
  • age >35 and smoking >15/d
  • major surgery and prolonged immobilisation
  • SLE with antiphospholipid antibodies

UKMEC 3 (risks usually outweigh benefits)

  • BMI >35
  • first degree relative with VTE < age 45
  • age >35 and smoking <15/d
  • immobility unrelated to surgery (e.g. wheelchair)

Co-cyprindiol (Dianette) should only be prescribed as a treatment for severe acne (where topical treatments and oral antibiotics have failed) or hirsutism (MHRA).

17
Q

How do CHC influence arterial risk?

A
  • 1-2 fold increased risk of MI and stroke
  • 1 to 2 extra cases per 10,000 women/year
  • not influenced by type of progesterone

Consider CV risk factors / UKMEC criteria

POP do not increase arterial risk

18
Q

UKMEC advice on CHC and arterial risk?

A

UKMEC 4 (absolute contraindications)

  • age >35 and smoking >15/d
  • migraine with aura
  • BP >160/95
  • h/o IHD, TIA or stroke
  • complicated valvular or congenital heart disease
  • SLE with antiphospholipid antibodies

UKMEC 3 (risk usually outweighs benefits)

  • age >35 and smoking <15/d
  • migraine with aura >5y ago
  • BMI >35
  • controlled hypertension
  • BP >140/90
  • diabetic with nephropathy, retinopathy, neuropathy or vascular disease
19
Q

What is the Evra patch and how is it used?

A

A CHC that delivers 20mcg ethinyloestradiol and 150mcg norelgestromin a day

Apply first day of menstruation and replace weekly for 3 weeks, week 4 patch-free

Reduced efficacy if weighing >90kg

If used preceding 7d then can remain detached 48hrs efore efficacy reduced, similarly patch-free interval can be extended to 9d.

FSRH endorses extended regimes as for CHC pills.

20
Q

Advice to give women using CHC when prescribing antibiotics?

A

Based on FSRH advice of 2011, no additional precautions are necessary.

The exception are enzyme-inducing drugs such as rifampicin/rifabutin.

Remind women that extra precautions are however required if they develop diarrhoea or vomiting.

21
Q

Advice regarding herbal remedies and hormonal contraception?

A

Avoid St John’s Wort with any hormonal contraceptive.

Ask about herbal remedies use in woman with unscheduled bleeding.

22
Q

Which drugs are enzyme-inducers?

A

Carbamazepine, eslicarabazepine, oxacarbazeine

Phenobarbitol, phenytoin, primidone

Rifampicin, rifabutin

Moderate: Topiramate, St John’s wort

Numerous HIV drugs

Not inducers: Benzos, Gabapentin/pregabalin, Lamotrigine, Levetiracetam, Valproate

23
Q

How long does the effect of enzyme-inducers last?

A

It begins within 2 days and can last up to 4 weeks, so extra precautions must be continued 4 weeks after cessation.

24
Q

Which contraceptive methods are affected by enzyme-inducers, which are not?

A

Affected by enzyme inducers: CHC, POP, SDImplant, Ullipristal and Levonelle

Not affected are: POI (DMPA injection), IUS, IUD

25
Q
A

General Practice UK (11 decks)

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